We’re all familiar with Akshay Kumar advising a random man outside a hospital to switch his cigarette with a sanitary pad to save his wife’s life. If not that, the sad, tragic tale of chain-smoker Mukesh, an ill man whose health status we were made uncomfortably privy to at the movies. These are initiatives by the Indian government to curb tobacco consumption in India — a country home to 99.5 million tobacco smokers, second only to China. Even as negative cultural perceptions of smoking evolve across the globe, in India, little has changed.

Despite the passing of several anti-smoking bills, the positive cultural perception of smoking remains almost stagnant — due to a lack of proper implementation of anti-tobacco laws, and awareness and knowledge amongst the people as to its harmful health effects. Research shows that while awareness among Indian youth — one of the main consumer populations — that tobacco is harmful, exists, they seem to know little to nothing about exactly how tobacco harms them, according to a review of tobacco control in India. This lack of knowledge further means their exposure to anti-tobacco messaging does not translate to the cessation of smoking, which in turn fails to change attitudes toward consuming tobacco.

Right now, tobacco consumption levels, assessed by surveys such as the Global Adult Tobacco Survey (GATS) and the National Family Health Survey (NFHS), rely on self-reporting by households, which makes determining the extent of the damage difficult — researchers say people tend to under-report their vices, such as tobacco consumption. While the latest GATS and NFHS reports show a reduction in tobacco consumption since 2010 — there has been a 6% decline in tobacco consumption rates — India still remains one of the major consumers of tobacco products in the world. With high consumption comes one of the largest burdens of tobacco-related diseases globally — the situation is direr than it seems as the government spends a mere 1.15% of the gross domestic product on healthcare, according to a 2018 study assessing tobacco consumption and control in India.

The crackdown on tobacco products in India has been gradual, and relatively ineffective. The anti-tobacco legislation, called the Cigarettes Act, was first approved at the Centre in 1975 — the main stipulation of the Act was compulsory inclusion of a warning on cigarette packets and in smoking advertisements: “Cigarette Smoking is Injurious to Health,” according to the World Health Organisation. This legislation largely excluded non-smoking tobacco use, like oral or nasal ingestion of substances such as chewing tobacco or gutka, which is more prevalent in large parts of India — especially amongst the lower socio-economic classes of Indian society.

Continuing its pattern of only regulating the commercial cigarette industry, the government decreed that smoking was a form of air pollution in 1981, and then made it illegal to smoke in a public vehicle in 1988. It was only in 1990 that the government put out an advisory stating that chewing tobacco was injurious to health. In 2000, the Cable Television Networks Amendment Act banned the advertising of tobacco and alcohol. One year later, (and finally) the original Cigarettes Act became the Cigarettes and Other Tobacco Products Act (COTPA) and was expanded to include cigars, bidis, pipe tobacco, hookah, chewing tobacco, and pan masala.

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COTPA also imposed other regulations on the consumption of tobacco that have historically succeded in bringing about changes in cultural perceptions of smoking (from ‘cool’ to ‘bad’) in the West — it banned advertisements of tobacco products, smoking in public, sale of tobacco to minors, and smoking within three to four feet of educational institutions, according to a review of tobacco legislation in India. COTPA also made it compulsory to include cautionary pictures of tobacco harm and imposed regulations on the tobacco industry regarding the tar and nicotine content of products. Around this time, some state governments also banned gutka and pan masala, according to the review.

It further adds that in 2008, India, after having signed a WHO Convention on Tobacco Control, amped up efforts to curb tobacco use in the country, releasing a National Tobacco Control Programme — covering 42 districts in 21 states and union territories. It was an information and capacity building effort to spread awareness about the health risks of tobacco, and collect information regarding tobacco consumption patterns that would inform future policies. The problem with the program, and with tobacco laws in the country, however, persist for the sole reason, that implementation hasn’t been ensured, and isn’t uniform across states or social classes, according to a review of tobacco control in India.

For example, tobacco companies, despite being banned from advertising their products, continue to do so surreptitiously, through tobacco-branded merchandise, such as T-shirts, caps, posters, belts, helmets and water bottles, according to a study of tobacco promotion in India. “For example, smokeless tobacco products are advertised through printing their pack shots and brand names on kites that children fly throughout India on Independence Day,” the study adds.

Despite efforts to curb tobacco marketing and sales by the government, the tobacco industry continues to target vulnerable populations, such as marginalized communities. The 2018 tobacco control and consumption study shows increased levels of marketing — in the form of billboards, flyers — in lower socioeconomic neighbourhoods. The brunt of poor tobacco control, then, is borne by the poor. Bidis (tobacco rolled in a temburim leaf) are popular among communities from lower socio-economic backgrounds; they are also cheap, easily accessible, contain three to five times nicotine than commercial cigarettes, and are produced by a largely unregulated industry that remains untouched by the government’s health campaigns or caution regulations.

Another market tobacco companies target, are the youth. They are targeted with innovative brand marketing, the 2018 study shows, in the form of flavored cigarettes, or with free cigarette dispensation at social events or public establishments. This increases the rate of “smoking experiments and consumption,” the study shows. A Reuters investigation revealed the world’s largest publicly traded tobacco brand, Philip Morris International Inc., was targeting Indian youth through colorful advertisements and free samples at clubs and parties in Delhi. These tactics are what Big Tobacco used in the West in the 1950s and 60s when smoking enjoyed its heyday. When successful public health efforts managed to change the perception of smoking and reduce smoking rates there, Big Tobacco changed its target, moving into developing economies such as India, where the laws were less strict, or ineffective, according to The Conversation.

While these marketing strategies by private companies permeate young communities across all strata of society, the government campaigns combating the messaging fail to reach the marginalized.

One of the methods to curb tobacco smoking that has worked in the U.S. is the ban of selling ‘loose’ cigarettes, while also raising the taxes on entire packs, making them more expensive. In India, with the widespread availability of singular, cheap cigarettes and bidis at almost every street corner disappears the incentive to save on cost. It is, however, a move the Indian government has been mulling over for the past four years.

Another problem is taxation on tobacco products: “India’s relatively high consumption is due in part to a historically low or no tax on bidis and an inefficient, complex system of taxing cigarettes,” according to a 2011 Economic and Political Weekly paper delineating the system of taxation on tobacco products in India. While deaths due to tobacco consumption have decreased in high-income countries where the governments have cracked down on the sale of tobacco with high taxes, there has been no such effect in India, due to its “informal economy,” “poor information systems,” and “ineffective regulation of tobacco products,” according to the paper.

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The dissonance between law and cultural acceptance of cigarettes is the most apparent in Bollywood, which often purports to be the mirror to Indian society. Even with mandatory warnings at the start of the reel where a lady spouts off the “cigarettes are injurious to health…” manifesto in an almost indecipherable voice, the way in which cigarette smoking is portrayed almost always refers to a ‘cool’ or ‘powerful’ character, which has often been the stereotype for smokers in society. And this portrayal, in turn, exacerbates the propensity to smoke amidst viewers, a study shows.

The study — of 3956 adolescents between 12-16-year-old — sought to assess the impact of 59 Bollywood movies (released between 2006 – 2008) with depictions of smoking on the kids, in 2009. The smoking depictions on-screen increased teen interest in smoking. Those who viewed more smoking portrayals were twice as likely to smoke than those who had seen fewer portrayals — a finding researchers said was in line with western studies that showed similar relationships between teens and Hollywood movies.

Today, the aforementioned Mukesh is a popular joke. People often cover up the rotten lung photos on cigarette packs with stickers. According to GATS, Indians are still smoking 6.2 cigarettes per day. Though researchers say doctors are one of the major vectors to counsel people to stop smoking — 50% of Indian male doctors are smokers, which dilutes their ability to be effective counselors. In light of such an ingrained, oftentimes celebrated habit, happily adopted by a majority of the population, it will take years of concerted, disciplined anti-smoking efforts by the government — in terms of spreading health awareness, providing skilled counselors, and implementing already existing laws across the board — to enforce strong enough negative perceptions of smoking and substantially lower rates of tobacco use.